2. This Uber account is designed to help participants get to and from their DUI Court programmatic obligations only. (i.e. the Drug Lab, Family Counseling Services, the Courthouse, and MedLink for appointments. We ask that you please give us a 24 hour notice). Please understand that submitting this request does not guarantee approval.
4. First Name*
5. Last Name*
7. Best Contact Phone Number *
9. Do you have a driver's license or a car?*

   1. Yes
   2. No
   3. Other
10. If you select "Other" please explain:
12. What is the date that you are requesting the Uber?*
    What is the date that you are requesting the Uber?
13. What time do you need the Uber to pick you up?
    What time do you need the Uber to pick you up?
15. Where will the Uber be picking you up from? (Please provide full address)
17. Address 1*
19. Address 2
21. City*
22. Zip*
26. Where will the Uber be taking you? (Please provide full address)
28. Address 1*
30. Address 2
32. City*
33. Zip*
37. Have you had a violation in the past 2 weeks? *

    Please note that if you answer yes to this question, your request will be staffed by the DUI Court Team before it can be approved.

    1. Yes
    2. No
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field